Symptom experience in Korean adults with lung cancer

Article Outline

• Abstract
• 1. Introduction
• 2. Methods
  • 2.1. Subjects
  • 2.2. Measurements
  • 2.3. Study procedure
  • 2.4. Data analysis
• 3. Results
  • 3.1. Demographic and clinical characteristics
  • 3.2. Symptom experience in adults with lung cancer
  • 3.3. Association of symptom distress and demographic variables
  • 3.4. Association of symptom distress and clinical variables
• 4. Discussion
• Acknowledgements
• References
• Copyright

Abstract 

This study aimed to examine how symptoms vary in relation to demographic characteristics (age and sex), stage of disease, histology of lung cancer, and treatment type in Korean adults with lung cancer. Symptoms were measured with the Symptom Distress Scale. A total 106 patients with a mean age of 60.9 (SD=10.38) years participated. The results indicated that 1) overall symptom distress was more severe (mean 32.74, SD 10.75) compared to the studies reported in Western countries, and 2) among the variables, only the stage of lung cancer showed a significant relationship with total symptom distress (P < 0.05). In analyses of the individual symptoms, bowel-related symptoms showed significant relationships with sex, age, and type of treatment. The results highlight the importance of symptom management as well as the need to tailor clinical interventions according to related factors in order to maximize effective symptom management in Korean patients with lung cancer.

Keywords:  Symptom distress, lung cancer, symptom management

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1. Introduction 

The high proportion of smokers and the incidence of advanced, unresectable lung cancer at diagnosis have urged development of a national anti-smoking program to promote the cessation of smoking and the early detection of lung cancer in Korea.¹ Nevertheless, lung cancer is the second most common cancer and the leading cause of cancer death in Korea.² According to the Korean cancer database, the mortality rate for lung cancer increased 53% during the last 10 years. Considering that the smoking rate of Korean men (61.8%) is the highest among the 31 Organization for Economic Cooperation and Development (OECD) countries and is increasing in women and adolescents, the prevalence and mortality rate for lung cancer is expected to further increase.³

Unfortunately, most people with lung cancer are diagnosed when they are already at an advanced stage of the disease.^1., ^4. According to a previous study conducted by the Korean Academy of Tuberculosis and Respiratory Diseases, two-thirds of the non-small cell lung cancer patients were detected in the unresectable advanced stages (IIIB and IV).¹ Chemotherapy, radiation, and/or surgery may be used to modify the illness trajectory. In cases of advanced lung cancer (Stage III-B, IV), chemotherapy and/or radiation therapy were generally chosen, whereas surgery is preferred for the early stage.

Lung cancer patients exhibit a wide range of serious physical and psychological symptoms that arise not only from the natural progression of the disease, but also from treatment-related side effects.^5., ^6. In lung cancer studies, it has been suggested that most people with lung cancer experience multiple and severe levels of symptoms caused by various factors. Factors previously found to affect symptoms are demographic characteristics such as age⁷ and sex,^6., ^7., ^8. stage of cancer,^7., ^9. and types of treatment.^6., ^10. However, these results are mostly from Western countries. In addition, previous studies have been focused on overall symptom distress, and data concerning symptom distress associated with individual symptoms are limited.

In a multicenter study of cancer pain and its management in advanced cancer patients in Korea, it was found that cancer pain is underestimated by the health care team and the assessment and management of pain are inadequate.¹¹ Although the study was limited to cancer pain, there may be similar effects pertaining to other cancer-related symptoms.

It is known that symptoms in the lung cancer group are more problematic than in other types of cancer groups,^7., ^12. and the trend is similar in Korea. One study has found that symptom occurrence was higher in lung cancer compared to the other types of cancer in Korea.¹³ However, information about how individual symptoms vary according to factors known to have a relationship with symptom experience in lung cancer patients is limited. Despite the high prevalence and mortality rate of lung cancer in Korea, research on symptoms is mostly done in patients with stomach, ovary, or breast cancer.¹⁴ No study has focused on the prevalence of symptoms or the correlates of the symptom experience in adults with lung cancer in Korea.

The purpose of this study was to examine how symptoms vary in relation to demographic (age and sex) characteristics, stage of disease, type of lung cancer, and treatment type in Korean patients with lung cancer.

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2. Methods 

2.1. Subjects 

The subjects were recruited over a five-month period between March 2001 and August 2001 from inpatient respiratory and oncology units at a large university hospital in Seoul, Korea. Eligible patients were required to: 1) be pathologically diagnosed as having lung cancer, 2) have been informed of their diagnosis, 3) be 18 years of age or older, 4) be able to understand and complete the questionnaire, and 5) agree to participate in the study.

2.2. Measurements 

Symptoms were measured with the Symptom Distress Scale (SDS),¹⁵ a self-report measurement that encompasses 11 symptoms: nausea, appetite, pain, fatigue, insomnia, bowel pattern, concentration, breathing, cough, outlook (the degree of fear and/or worry), and appearance. The SDS was translated into Korean by the investigator and was verified in two bilingual nursing faculties whose academic concentrations are in oncology. Each symptom was described on a five-point scale ranging from 1 (least distress) to 5 (extreme distress). In addition, two of the symptoms, pain and nausea, are rated on a five-point Likert frequency scale, ranging from 1 (infrequently) to 5 (constantly). This resulted in 14 symptom scores: a total symptom score and a score for each of the 13 symptoms. The total score was calculated by adding the raw scores of the 13 symptoms; thus, the range of the total symptom score was from 13 to 65. The SDS scale was developed in a population of ambulatory cancer patients, with reliability levels as assessed by Cronbach's alpha ranging from 0.79 to 0.83 in previous research.^12., ^15., ^16. In this study, the Cronbach's alpha of the 13-item SDS was 0.87.

Demographic information, such as age and sex, and clinical information, such as stage, current treatment type, and histology, were obtained from the subjects' medical records. Stage of disease was classified according to the TNM classification of lung cancer using the International Staging System,¹⁷ which classifies tumors on a scale of 0 (carcinoma in situ) to IV (distant metastasis). Stages A and B for each stage were collapsed into one stage. A check of cell size in the disease stage revealed a very small sample size in Stages I (n=3) and II (n=6); thus, the disease stage variable was collapsed into early (Stage I, II) and late (Stage III, IV) stages. Types of treatment included chemotherapy, radiotherapy, surgery, and no current treatment. Because only one patient was identified as having surgery, the surgery category was eliminated from the analysis. No patient was identified as having a mixed protocol in terms of treatment type. Type of lung cancer included small cell, squamous cell, adenocarcinoma, and unspecified.

2.3. Study procedure 

With the help of the clinical staff, patients were approached and the study purpose was described. Each patient who agreed to participate was given a consent form and all questions were answered. Rights of the participants were protected through approval of the institutional review board. Data were collected by a research assistant who was trained in interviewing by the investigator. Each interview lasted approximately 30 minutes.

2.4. Data analysis 

Descriptive statistics were used to describe the overall characteristics of the subjects in terms of demographic and clinical variables, and symptom distress. The associations between symptom distress and study variables were tested using independent t-tests, Pearson's correlation coefficient, and/or ANOVA according to the study variables. For all statistics, the significance level was set at 0.05.

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3. Results 

3.1. Demographic and clinical characteristics 

A total 106 lung cancer patients with a mean age of 60.9 (SD=10.38) years participated in the study. Most subjects were men (76.4%), married (92%), older than 51 years of age (84%), retired and/or unemployed, and moderately educated (Table 1). Most had advanced lung cancer (34% in Stage III, 57% in Stage IV). Forty-seven subjects (45%) had adenocarcinoma, and 30 (29%) had squamous cell lung cancer. Fifty-five subjects (52%) received chemotherapy. Forty-three subjects (42%) were not having any treatment at the time of the interview. Time since diagnosis ranged from one week to 36 months, with a mean of 5 months. Further information about the clinical characteristics is presented in Table 2.

Table 1. Patient Demographic Characteristics (n=106)

Table 2. Patient Clinical Characteristics (n=106)

3.2. Symptom experience in adults with lung cancer 

The total symptom score (mean 32.74, SD 10.75) indicated that subjects had severe symptom distress. Of the 13 symptoms, the most severe symptoms were poor appetite (mean 3.13, SD 1.39), fatigue (mean 2.97, SD 1.20), outlook (mean 2.76, SD 1.12), and cough (mean 2.74, SD 1.38). The least severe symptom was identified as bowel-related symptoms (mean 1.85, SD 1.06), such as constipation and diarrhea. Detailed information about symptom experience is presented in Table 3.

Table 3. Patient Symptom Distress Scores (n=106)

3.3. Association of symptom distress and demographic variables 

Total symptom distress was not related to age (r=0.08, P=0.45). Of the 13 symptoms, loss of appetite only showed a weak positive relationship with age (r=0.23, P=0.02). Sex was also not related to total symptom distress. The mean score of the total symptom was slightly higher in women (mean 33.08, SD 10.4) than in men (mean 32.62, SD 10.93), but statistical difference was not found between the two groups (t=−0.18, P=0.86). However, of the 13 symptoms, women had more severe bowel-related symptoms (mean 2.24) than men (mean 1.73) (t=−2.15, P=0.03).

3.4. Association of symptom distress and clinical variables 

The mean score for the SDS by cancer stage is presented in Table 4. The t-test revealed that the mean score for total symptoms was significantly higher in patients with advanced stage than patients in early stage (t=2.51, P=0.01). Of the 13 symptoms, the advanced cancer group (Stages III and IV) had a more severe loss of appetite, more pain (both intensity and frequency), less concentration, greater change in appearance, insomnia, and more frequent nausea.

Table 4. Mean (SD) Score of the Symptom Distress Scale by Cancer Stage

	Early (Stages I & II) (n=9)	Late (Stages III & IV) (n=91)	t-value
Appetitea	2.22 (1.30)	3.21 (1.38)	2.06b
Fatigue	2.63 (1.06)	2.98 (1.47)	0.80
Outlook	2.11 (0.93)	2.85 (1.11)	1.91
Cough	2.11 (1.17)	2.75 (1.38)	1.34
Pain (frequency)	1.50 (1.07)	2.79 (1.68)	3.09b
Concentration	1.67 (0.87)	2.76 (1.31)	2.44b
Appearance	1.75 (0.71)	2.66 (1.39)	3.14c
Pain (intensity)	1.33 (0.50)	2.68 (1.47)	5.93c
Insomnia	1.67 (1.12)	2.55 (1.26)	2.03b
Breathing	1.88 (1.13)	2.49 (1.33)	1.26
Nausea (frequency)	1.25 (0.46)	1.95 (1.35)	3.21c
Nausea (intensity)	1.56 (0.73)	1.90 (1.13)	0.91
Bowel	1.67 (0.71)	1.86 (1.09)	0.50
Total score	23.14 (6.47)	33.30 (10.53)	2.51b

The mean score for total symptoms was not significantly different according to the histology of lung cancer [F(3,97)=1.16, P=0.33]. Of the 13 symptoms, however, pain frequency was significantly different according to the histology of lung cancer [F(3,101)=3.76, P=0.013]. Post-hoc test revealed that patients in the unspecified lung cancer group had more frequent pain than those in the small cell lung cancer group (t=−1.72, P < 0.05) and than those in the squamous cell lung cancer group (t=−1.74, P < 0.01).

Symptom scores according to treatment are presented in Table 5. ANOVA indicated that the mean total symptom score was not significantly different across the various treatment types [F(4,95)=1.06, P>0.05]. Of the 13 symptoms, however, cough [F(4,99)=3.38, P=0.01] and bowel-related symptoms [F(4,99)=2.98, P=0.02] were significantly different according to treatment type. Coughing was more severe in the group not currently on treatment than in the group on chemotherapy with the regimen of docetaxel/cisplatin (t=1.36, P=0.03). Bowel-related symptoms were more severe in the radiotherapy group than in the group on chemotherapy with the regimen of docetaxel/cisplatin (t=1.67, P=0.02), those on other chemotherapies (t=1.50, P=0.02), and the group not on treatment currently (t=1.38, P=0.02). When symptom scores were analyzed according to status of receiving any treatment (combining all treatment vs. no treatment), coughing (t=−3.47, P=0.001) and pain frequency (t=−2.85, P=0.005) were more severe in the group not currently on treatment, whereas nausea intensity was more severe in the treatment group (t=2.06, P=0.04).

Table 5. Mean (SD) Score of the Symptom Distress Scale by Treatment Type

	Chemotherapy Group
Symptom	V/I/C (n=27)	D/C (n=10)	Etoposide (n=18)	Radiotherapy (n=6)	No treatment (n=43)
Appetite	3.26 (1.58)	3.2 (1.55)	2.82 (1.20)	2.67 (1.37)	3.23 (1.36)
Fatigue	2.74 (1.26)	3.2 (0.92)	2.82 (1.24)	3.0 (1.41)	3.12 (1.2)
Outlook	3.11 (1.12)	2.4 (1.26)	2.72 (1.02)	3.0 (1.26)	2.63 (1.07)
Cougha	2.56 (1.34)	1.9 (0.9)	2.28 (1.13)	2.5 (1.05)	3.26 (1.47)
Pain (frequency)	2.22 (1.58)	2.2 (1.93)	2.0 (1.5)	3.33 (1.63)	3.21 (1.59)
Concentration	2.85 (1.38)	2.3 (1.16)	2.11 (1.13)	3.17 (1.72)	2.77 (1.27)
Appearance	2.78 (1.31)	2.5 (1.65)	2.65 (1.41)	3.33 (1.63)	2.35 (1.31)
Pain (intensity)	2.41 (1.42)	2.5 (1.65)	1.89 (1.37)	2.83 (1.47)	2.86 (1.42)
Insomnia	2.52 (1.40)	2.1 (0.99)	2.06 (1.21)	2.33 (1.37)	2.77 (1.27)
Breathing	2.42 (1.30)	2.1 (1.37)	2.06 (1.14)	2.5 (1.22)	2.74 (1.43)
Nausea (frequency)	2.22 (1.48)	1.3 (0.67)	1.88 (1.05)	2.33 (1.63)	1.77 (1.39)
Nausea (intensity)	2.19 (1.18)	1.5 (0.71)	2.17 (1.29)	2.17 (1.47)	1.6 (0.93)
Bowelb	1.89 (0.85)	1.5 (0.85)	1.67 (1.08)	3.17 (1.47)	1.79 (1.06)
Total	32.62 (11.04)	28.7 (8.35)	29.63 (8.94)	36.33 (12.03)	34.21 (11.34)

Chemotherapeutic drugs for lung cancer patients: V=Vinorelbine; I=Ifosfamide; C=Cisplatin; D=Docetaxel.

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4. Discussion 

This is the first paper that has looked at the symptom experience in relation to the general and clinical characteristics in adults with lung cancer in Korea. In general, a severe level of symptom distress prevailed for the subjects in this study. The most important finding of this study is the large number of people with high symptom scores on no current treatment, indicating that palliative measures and symptom management to obtain some relief are essential. The mean total symptom score of the SDS in this sample (mean 32.74, SD 10.75) was higher compared to previous studies performed in Western countries. Previous studies have reported moderately high symptom distress (approximately 27–29) in lung cancer patients.^5., ^7., ^18. A possible explanation for the high score of the symptom distress in this sample could be the relatively large portion of patients with an advanced stage of disease. The percentage of the advanced group (91% of Stages III and IV) in this study was higher than in previous studies.^5., ^18. In addition, compared to these studies, a relatively large portion of subjects were receiving active treatment with chemotherapeutic agents, such as vinorelbine/ifosfamide/cisplatin. This may explain the result that loss of appetite was the most significant problem, followed by fatigue, negative outlook, and cough in lung cancer patients. Nausea and bowel-related symptoms were relatively less severe for these subjects. The symptoms experienced by the patients were similar to the previous result that fatigue, pain, loss of appetite, cough, and insomnia are the most problematic symptoms in newly diagnosed patients with lung cancer.⁷

Older patients tended to have less symptom distress than younger patients. In this study, although it did not yield statistical significance, patients older than 60 years generally experienced less total symptom distress. However, poorer appetite was more severe in older patients than younger patients (r=0.23). These results replicate previous research, which found a weak correlation between age and symptom distress (r=−0.11).⁷

Although women had higher total symptom distress than men, there was no sex difference in total symptom score. This result is similar to that in the previous study by Krech and associates,¹⁹ which found no sex difference in symptoms. However, others have reported that women with lung cancer have more symptom severity, as measured with the SDS.^5., ^7. Cooley et al.⁵ found that sex was a significant determinant of symptom distress only at baseline in longitudinal symptom distress patterns in adults receiving treatment for lung cancer. This study found that women had more severe bowel-related symptoms. Further research is needed to identify sex differences in individual symptom experience.

Lung cancer patients in the advanced stage had more symptom severity than those in the early stage. This is expected and the results are consistent with previous studies.^7., ^9. This result implies that the health care team should give more attention to symptom management in patients with lung cancer because most adults with lung cancer present with advanced stages of disease, and this group is more vulnerable to symptom distress.²⁰

Symptom distress did not significantly vary in histology of the lung cancer. This result is consistent with a study done by Hopwood and Stephens.⁸ They found no difference in symptom distress between a small cell lung cancer group and a non-small cell lung cancer group. However, Cooley et al.⁵ reported that histology was a significant determinant of symptom distress at baseline, although it was not significant at the 3-month point.

Among the treatment types, the radiation therapy group tended to report more severe symptoms. The chemotherapy group receiving the regimen of docetaxel/cisplatin had less symptom severity compared to the chemotherapy group with a mixed regimen of vinorelbine/ifosfamide/cisplatin, although this was not statistically significant. This is similar to a previous report in Korea,¹³ which indicated that the radiation group and combined therapy group with radiation and chemotherapy reported more symptom distress than simple chemotherapy.

Although there was no statistical difference in total symptom distress among types of treatment, individual symptom differences were found. The radiation group had more severe bowel-related symptoms, and both cough and pain frequencies were more problematic in groups with no current treatment at interview. In this study, the majority of subjects had an advanced stage of lung cancer, and most subjects were receiving chemotherapy or radiation rather than surgery. Aggressive treatment may not be preferred in patients with advanced disease. Thus, it may be difficult to compare symptom distress accurately among surgery, radiation, and chemotherapy groups. In a study conducted by Cooley et al.,⁵ the type of treatment was a significant determinant of symptom distress in early stage lung cancer patients. Specifically, the surgery group exhibited a significantly lower mean total score than did the combined therapy group or the radiation therapy group. This may suggest that treatment type is an important factor contributing to symptom distress, especially in the early stage of lung cancer. These findings suggest the need to tailor clinical interventions according to the type of treatment that adults with lung cancer receive.

This study involved a convenience sample, a cross-sectional design, and patients in a limited geographic region. These factors may limit the generalizability of the findings. Another major limitation may be unequal sample size in each of the study variables. Because of unequal sample size, it was difficult to analyze interaction effects among the study variables. Thus, the findings of this study must be interpreted with caution.

Despite the limitations discussed above, the present study suggests that there may be differences in the experiences of symptoms according to various factors. Recognizing these features may provide useful information for directing future research and practice for better management of lung cancer patients in Korea. Based on the results of this study, the following studies are suggested: 1) an analysis of the interaction effects between the study variables; 2) longitudinal studies that examine patterns of the individual symptom distress; and 3) an examination of effects of symptom distress on functional status and/or quality of life in patients with lung cancer.

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Acknowledgements 

This study was supported by the Faculty Development Fund from Yonsei University, Seoul, Korea.

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